There’s still ambiguity in how surveyors will interpret new elements of survey changes, but tightening up documentation to best reflect a resident’s condition and care plan goals will be key for nursing homes adjusting to these.

According to operators who’ve begun implementing these changes, the new survey effective April 28 aims to improve assessment accuracy, and major pitfalls lie in lack of updated documentation, especially when it comes to discharge planning and administering antipsychotics, as well as pharmacological interventions. The changes also require a more careful monitoring of Minimum Data Sets (MDS), with less room allowed for mistakes.

Having medical records that best tell the resident’s story, and explains why clinical staff is doing what they’re doing, will be lifesavers for operators in the days to come, said Michelle Stuercke, chief clinical officer for Transitional Care Management.

Stuercke discussed the surveyor changes along with Heather Haberhern, senior vice president of operations and onboarding for Health Dimensions Group; and Jody O’Mara, chief nursing officer for Indiana operator Journey during a Skilled Nursing News webinar.

Panelists confirmed that CMS will be focusing greater attention on transfers and discharges as well as psychotropic medications, while also digging into medical records on site to ensure documentation is reflective of decision making between staff, residents and their representatives.

Journey has been educating their medical directors and nurse practitioners about unnecessary antipsychotics, especially in certain regions, with facilities in Georgia prescribing such medications at higher percentages than other regions in which they operate, O’Mara said.

A lot of the changes had assessment accuracy at the heart, Haberhern said, and these care plans will need to be reviewed and updated with every change in a resident’s condition or any new medication order.

The new survey helps “paint the picture of our interventions and the steps that we’re going to take to avoid hospitalizations, to prepare for successful discharges, as well as the steps that we’re taking prior to prescribing any new medications,” Haberhern said.

Special attention to MDS inaccuracies, AI referrals

Inaccuracies in the Minimum Data Set (MDS) should be monitored closely as well, Stuercke said, with guidance for surveyors stating that three or more inaccuracies could automatically move a citation to a more serious scope and severity level.

When it comes to transfers and discharges, operators should look at the referral process to make sure they don’t end up with a patient they need to send back, especially if there’s a scenario where AI was used in referrals from the hospital, O’Mara said.

“I think the consequences from that would be very serious,” added O’Mara.

That said, not everything is clear cut. Operators are closely watching how surveyors will interpret some of the changes, particularly around antipsychotics, Stuercke said. Moving forward, nursing home leaders must pay attention to how surveyors in their area are interpreting these critical element pathways, she noted.

Moreover, more clarity is needed on changes around QAPI, Haberhern said, and what is being reported from metrics. There wasn’t much information in the critical element pathway for QAPI changes.

“CMS is asking us to include health equity information. From our standpoint, what we’re including and how we’re interpreting that information is really left up to us,” said Haberhern. “I think it would be helpful for CMS to give us a few examples of what they’re looking for and how they’re going to be assessing that situation.”

O’Mara said more guidance and clarification will likely come from feedback after the updated surveys have been conducted.

“The more surveys we have, the more we’ll learn. I think [the surveyors are] also under a bit of a learning curve,” added Stuercke.

Haberhern agreed, stating that surveyors are learning alongside operators. It’s not a perfected process and it’s good to remember that surveyors and operators are “in this together.”

Best advice for the days ahead

A good rule of thumb would be to have a debriefing of sorts after a new survey is done, said Haberhern, to see if there was a focus on one specific area and how the medical director got involved, or if the region’s ombudsman was contacted in advance of the survey.

Operators will be learning as they go, she said, similar to experiences with facility assessments tied to the staffing mandate. Standalone facilities should communicate with neighboring nursing homes, while operators with more than one facility should have each building in communication after surveys are done.

Overall, nursing home operators should be making sure all of their processes are in place, staff is educated on the surveyor changes and really prep staff on how to answer surveyor questions. Mock surveys using information from critical development pathways is like giving staff “answers to the test” ahead of time.

With discharge planning, for instance, Stuercke said that staff needs to be careful in explaining when a managed care plan no longer covers their nursing home stay. It can be confusing and a source of anxiety for residents who think they need to leave the facility, when in reality a discussion needs to happen where options for a shift in coverage are outlined.

“Going through some of these scenarios, going through some of the potential questions, using those critical element pathways … Those are the answers to the test. Use [the critical element pathways] to design some scenarios to help your staff feel confident in their answers,” said Stuercke.

State association conferences will help with survey messaging too, which O’Mara said is a “bridge” between surveyors and nursing homes.